Asian Journal of Transfusion Science
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CASE REPORT Table of Contents   
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 142-144
Masquerading of mismatched blood transfusion by underlying autoimmune hemolytic anemia


1 Department of Clinical Hematology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Pathology, Division of Hematology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
3 Department of Transfusion Medicine, Aapollo Gleneagles Hospital, Kolkata, West Bengal, India

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Date of Submission26-Dec-2017
Date of Acceptance08-Jun-2018
Date of Web Publication3-Dec-2019
 

   Abstract 


Mismatched blood transfusion due to immunohematological discrepancy is relatively uncommon and in most instances occurs due to Type IV blood group discrepancy which is the discrepancies between forward and reverse groupings. Here, we present a case of a 15-year-old girl with preexisting autoimmune hemolytic anemia (AIHA) who inadvertently received 3 units of wrongly matched packed red blood cell (PRBC), followed by severe intravascular hemolysis. On detailed immunohematological investigation, the patient was found to be autoimmunized and diagnosed with “mixed AIHA” and the patient's blood group was confirmed as “A” positive. Three units of group-specific “best match” PRBC was transfused under close observation without any adverse effect. This highlights the importance of carrying out both forward and reverse blood groupings to avoid mismatched blood transfusion.

Keywords: Mismatched blood transfusion, mixed autoimmune hemolytic anemia, life threatening complication

How to cite this article:
Samal P, Pradhan S, Das SS. Masquerading of mismatched blood transfusion by underlying autoimmune hemolytic anemia. Asian J Transfus Sci 2019;13:142-4

How to cite this URL:
Samal P, Pradhan S, Das SS. Masquerading of mismatched blood transfusion by underlying autoimmune hemolytic anemia. Asian J Transfus Sci [serial online] 2019 [cited 2019 Dec 13];13:142-4. Available from: http://www.ajts.org/text.asp?2019/13/2/142/272050





   Introduction Top


Mismatched blood transfusion due to immunohematological discrepancy is an uncommon phenomenon. In most instances, ABO-incompatible transfusion occurs due to Type IV blood group discrepancy which is the discrepancies between forward and reverse groupings. It occurs mostly due to miscellaneous causes such as warm or cold autoantibodies, unexpected ABO isoagglutinins, unexpected alloantibodies, and polyagglutination. It is more commonly attributable to the autoantibodies in a case of autoimmune hemolytic anemia (AIHA).[1] Such mismatched transfusion may at times be fatal with incidences reported between 5.5% and 30%.[2] We report a case of mismatched blood transfusion in a young girl with underlying AIHA who survived intravascular hemolysis following three units of ABO-incompatible blood transfusion after appropriate resuscitation. Herein, we discuss the need of communication with blood bank personnel about underlying AIHA while performing blood grouping for transfusion and also stress upon the fact that a blood grouping is incomplete without performing the reverse (serum) grouping/typing of the blood.


   Case Report Top


A 15-year-old girl (consented) presented in the emergency department with fever with chills, respiratory distress, and passage of coca-colored urine. The patient had a history of three units of “AB-” positive packed red blood cell (PRBC) transfusion at a local hospital. On evaluation, she had severe pallor and icterus and was hypotensive, dehydrated, restless, and dyspneic. Laboratory values revealed hemoglobin (Hb, 3.8 g%), reticulocytosis (12.7%), total serum bilirubin (s. bili, 12.2 mg/dL), serum LDH (sLDH, 2850 U/L). Peripheral blood smear shows marked agglutination of red cells. With existingin vivo hemolysis and severe anemia, requisition and blood samples were sent to blood bank for blood transfusion. Owing to incompatible crossmatches, detailed immunohematological investigation was performed in the blood bank [Table 1]. The patient was found to be autoimmunized and diagnosed with “mixed AIHA.” In AIHA, the forward group discrepancy is caused by autoantibody-coated red cells which nonspecifically react with all monoclonal antisera used. In addition, the free autoantibody in the patient's serum is the cause of reverse group discrepancy where autoantibodies react nonspecifically with the reagent “A,” “B,” and “O” cells used for reverse grouping.[3],[4] Based on this principle, the patient's red cells were subjected to cold acid elution, and serum was subjected to alloadsorption. The eluted red cells and adsorbed serum were then used for forward and reverse groupings, respectively, to solve the discrepancy. This confirmed the patient's blood group as “A” positive, and 3 units of group-specific “best match” PRBC was transfused under close observation without any adverse effect.
Table 1: Immunohematological details of the patient

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The patient was managed optimally by blood transfusion and steroids. Adequate diuresis was maintained for clearing the metabolites of mismatched transfusion. The patient improved clinically and symptomatically and maintained a Hb of 10.3 g% within 4 days of treatment. On the 5th day, she again became pale and Hb dropped to 5.2 g%. She received further 3 units of “best match” PRBC and rituximab in view of the high titer (1:1024) of cold agglutinin. There was no further fall in Hb, and laboratory values depicted a reduction in thein vivo hemolysis. At discharge, the patient was stable with Hb, s. bili, and sLDH of 12.5 g%, 2.1 mg/dL, and 750 U/L, respectively. She was advised to visit the hematology outdoor after a week.


   Discussion Top


Determination of ABO blood group in AIHA is a frequent problem encountered by the blood bank personnel due to discrepancy between forward and reverse groupings. Zhu et al. performed ABO typing in 38 AIHA patients and found 11 cases (31.6%) showing ABO discrepancy, and all these patients were highly reactive for indirect agglutination test.[5] Garratty in 1993 described false-positive Rh typing results in AIHA when using reagents containing potentiators (e.g., albumin).[6] In the present case, the blood group was mistyped as “AB” positive probably due to nonspecific agglutination of the patient's red cells with the antisera used and failure to perform a reverse group and pretransfusion testing as per recommended protocol. This led to transfusion of “AB-” positive PRBCs in the “A-” positive patient.

Life-threatening complications of mismatched blood transfusion are rare but can occur.[2] Important factors that determine the severity of hemolytic reaction due to mismatched transfusion include blood volume, rate of infusion, patient age, comorbid conditions, isoagglutinin titer, and rapidity of initiation of appropriate treatment. Janatpour et al. observed severe signs and symptoms of transfusion reaction in patients receiving >50 mL of ABO-incompatible blood. They also discussed that deaths only occurred in patients who received >50 mL of incompatible blood although the finding was not statistically significant.[7] The patient survived the high-volume incompatible transfusions because of her young age, low isoagglutinin titer (anti-B titer: 1:32), the absence of comorbid conditions, and the rapidity of commencement of management.

Immunoglobulin M (IgM) antibodies have low-affinity interactions and less specificity compared to IgG antibodies. High concentration of free IgG autoantibodies in this patient, which have high affinity and multiple specificities to self-antigens, might have reduced the ABO antigen–antibody interaction leading to a less severe form of ABO-incompatible hemolytic transfusion reactions.[8]

The patient under study had a high titer of serum warm and cold autoantibodies reacting at wide thermal amplitude [Table 1]. These free autoantibodies interfered with the pretransfusion testing as well as activated the complement pathways strongly. Severe extravascular and intravascular hemolysis was caused by the significant red cell bound IgG and complements (C3d). No underlying alloantibody was detected using alloadsorption technique.[9]

Despite significant serological incompatibility, we transfused several units of PRBC based on the clinical condition. Das and Chaudhary discussed that no critical patient should be denied blood transfusion due to serological incompatibility, and the patient may be transfused “best match” units after performing few important simple tests.[10]


   Conclusion Top


A blood grouping is incomplete without performing the reverse (serum) grouping/typing. It is mandatory to perform reverse grouping using the known “A,” “B,” and “O” cells. The sensitized red cells and free autoantibodies in serum in a case of AIHA may cause blood group discrepancy (Type IV). In the index case, sensitized red cells were subjected to cold acid elution and serum subjected to alloadsorption. The eluted red cells and adsorbed serum were then used for forward and reverse groupings, respectively, to solve the discrepancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Harmening DM, editor. The ABO blood group system. In: Modern Blood Banking & Transfusion Practices. 6th ed.: F.A. Davis Company. Philadelphia, USA:2012;439-74.  Back to cited text no. 1
    
2.
Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in new york state: An analysis of 10 years' experience. Transfusion 2000;40:1207-13.  Back to cited text no. 2
    
3.
Bercher ME. ABO, H and Lewis blood groups and structurally related antigens. In: American Association of Blood Banks Edition. Technical Manual. 15th ed. Bethesda, Maryland: AABB; 2005. p. 289-313.  Back to cited text no. 3
    
4.
Das SS, Chaudhary R. Transfusiuon support in autoimmune hemolytic anemia. Indian J Hematol Blood Transfus 2006;1:9-13.  Back to cited text no. 4
    
5.
Zhu JY, Lan JC, Hu LY, Meng QB, Luo HQ. Study on blood ABO typing in patients with autoimmune hemolytic anemia. Zhongguo Shi Yan Xue Ye Xue Za Zhi 2004;12:525-7.  Back to cited text no. 5
    
6.
Garratty G. Problems associated with compatibility testing for patients with autoimmune hemolytic anemia. Southeast Asian J Trop Med Public Health 1993;24 Suppl 1:76-9.  Back to cited text no. 6
    
7.
Janatpour KA, Kalmin ND, Jensen HM, Holland PV. Clinical outcomes of ABO-incompatible RBC transfusions. Am J Clin Pathol 2008;129:276-81.  Back to cited text no. 7
    
8.
Frank SA. Specificity and cross-reactivity. In: Immunology and Evolution of Infectious Disease. Princeton (NJ): Princeton University Press; 2002.  Back to cited text no. 8
    
9.
Das SS, Chaudhary R. Utility of adsorption techniques in serological evaluation of warm autoimmune haemolytic anaemia. Blood Transfus 2009;7:300-4.  Back to cited text no. 9
    
10.
Das SS, Zaman RU, Safi M. Incompatible blood transfusion: Challenging yet life saving in the management of acute severe autoimmune hemolytic anemia. Asian J Transfus Sci 2014;8:1-4.  Back to cited text no. 10
    

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Correspondence Address:
Sarita Pradhan
IMS and SUM Hospital, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajts.AJTS_154_17

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